Over 4,080 women had delayed CervicalCheck results communicated to them as a result of an IT problem at a US lab.
A HSE-ordered review into the latest controversy finds around 800 of the test results weren't sent to either the women or their GPs.
In the other 3,200 cases, the results were issued to doctors but not to the women concerned.
The report says the Quest Lab was added as a CervicalCheck facility without proper due diligence or risk assessment.
It recommends the State develops a National Laboratory for Cervical Testing to avoid relying on outsourcing of tests.
*Reporting by Shane Beatty